If you have a chronic illness or disability, you may find yourself visiting the emergency room for urgent issues related to your health. Typically, these ER visits are reserved for severe flare-ups or circumstances that arise when your primary care doctor is unavailable. But how do we determine what qualifies as an emergency, and who has the authority to make that call?
For those enrolled in Anthem Blue Cross/Blue Shield in Georgia, Missouri, or Kentucky, a new policy could influence your decisions regarding ER visits. Starting July 1, Anthem members will be liable for the costs of their ER visits if deemed non-emergency. “Reserve the ER for actual emergencies — or you’ll have to pay,” states a letter sent to members in Georgia, as reported by NBC News. The message emphasizes the importance of keeping emergency rooms accessible for true emergencies.
Defining an Emergency
Anthem defines an emergency as a medical or behavioral condition that arises suddenly and is severe enough that a reasonable person would believe immediate care is essential to avoid serious harm to oneself or others. Examples include chest pain, stroke, poisoning, severe breathing difficulties, and other acute conditions.
An Anthem spokesperson explained to NBC News that the policy aims to discourage unnecessary ER visits, encouraging members to consult their doctors first. However, the final decision on whether a visit qualifies as an emergency rests with the insurance company. If they conclude it was not an emergency, the patient may be left with the financial burden.
Exceptions to the Policy
Notably, this policy does not apply to children under 14, visits on holidays or Sundays, or cases where there are no urgent care centers within a 15-mile radius. The intention is to guide patients towards telemedicine and urgent care options instead of the emergency room.
Criticism from Medical Professionals
The American College of Emergency Physicians (ACEP) criticizes this policy, stating it undermines sound medical practices and may even violate federal law. According to the ACEP, making patients accountable for ER visits that are ultimately not emergencies contradicts the “prudent layperson” standard, which is protected under federal regulations, including the Affordable Care Act.
Dr. Sarah Williams, ACEP’s president, argues that it’s unrealistic to expect patients to accurately assess their medical emergencies. “Most individuals seek emergency care appropriately, as evidenced by statistics from the CDC. The prudent layperson standard is essential and should remain in any healthcare reform discussions,” she added.
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In summary, Anthem Blue Cross/Blue Shield’s new policy could significantly impact how members approach emergency medical care, with potential legal ramifications and concerns about patient self-diagnosis.